Changing trend in prevalence of intestinal parasites in patients attending a tertiary care hospital in Lucknow

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1 Original Article Changing trend in prevalence of intestinal parasites in patients attending a tertiary care hospital in Lucknow Sanjeev Sahai 1* and Sana Jamali 2 1Assistant Professor, Department of Microbiology Associate Professor, Department of Microbiology, Integral Institute of Medical Sciences, Lucknow (U.P.), India 2Assistant Professor, Department of Microbiology, Integral Institute of Medical Sciences, Lucknow (U.P.), India. Corresponding author : Sanjeev Sahai Abstract Background: Intestinal parasitic infections are one of the commonest causes of morbidity in third world countries including, India. The aim of this study was to determine the prevalence of common intestinal parasitic infections in relation to demographic details of patients, attending a tertiary care hospital in Lucknow. Materials and Methods: A retrospective study was conducted from 1 st January 2014 to 31 st December 2014 in the Department of Microbiology, of Integral Institute of Medical Sciences and Research, Dasauli, Kursi road, Lucknow. A total of 755 samples from patients attending the OPD and IPD of the hospital with gastrointestinal symptoms were included in the study. Results: Out of total 755 samples, 133 (17.6%) samples were found to be positive for at least one parasite. Entamoeba histolytica was the most common parasite (9.3%) followed by Blastocystis hominis (3.3%), Giardia lambia (3%), Ascaris lumbricoides (1.3%), Ancylostoma duodenale (0.4%) and Hymenolepis nana (0.3%). Infection was more common in males (10%) than females (7.55%), yrs. age group (40%). Conclusion: Intestinal parasitic infection is quite high and intestinal protozoa are more common than helminths in our study. We are first to report high prevalence of B. hominis in stool samples from North India. This study emphasizes the need to study further the reasons behind decrease in prevalence of helminthic intestinal parasites along with health education, good sanitation, personal hygiene, and health awareness to decrease prevalence of intestinal protozoa. Introduction ranges from 12.5% to 66% with varying prevalence Intestinal parasitic infections are globally endemic rate for individual parasite (5,6). Globally, the and constitute major public health problem, intestinal parasitic infections such as soil-transmitted especially in the tropical and subtropical regions helminth (STH) and protozoa infections have been (1,2). They are widely prevalent in third world recognized as one of the most significant causes of countries due to poor sanitation, inadequate personal illnesses and diseases especially among hygiene, low level of education and lack of disadvantaged communities (7). In India prevalence awareness about safe drinking water (3). According of the protozoa infections is higher than that of to the World Health Organization (WHO), more than helminths with E. histolytica leading with a one billion (almost 15-20%) of the world's population prevalence of 43.9% (8). Amoebiasis, Giardiasis, is chronically infected with parasites (4). In India Ascariasis, Hookworm infection, and Trichuriasis are overall prevalence rate of intestinal parasitic infection among the most common intestinal parasitic 560

2 infections worldwide. These infections are responsible for high levels of morbidity and mortality, nutritional deficiencies including iron deficiency anemia, seizures, portal hypertension, chronic diarrhea and impaired physical development in children (9, 10, 11). The aim of this study was to determine the prevalence of common intestinal parasitic infection in relation to demographic, socioeconomic status as well as the seasons of the year in patients attending an upcoming tertiary care hospital in North Lucknow. Materials and Methods: A retrospective study was conducted during the period of 1 st January 2014 to 31 st December 2014 in the Department of Microbiology laboratory of Integral Institute of Medical Sciences and Research, Dasauli, Kursi road, Lucknow. The study was approved by the Institutional Ethical Committee. A total of 755 stool samples from patients having complaints of gastrointestinal symptoms attending Integral Institute of Medical Sciences and Research hospital were processed. All samples were subjected to routine macroscopic and microscopic examination. Macroscopic examination included colour, consistency, presence of mucus / pus / blood / any parasite. Microscopic examination was done by normal saline and Lugol s iodine wet mount preparation after Formol Ether sedimentation technique and observed under low (10x) and high (40x) power. The mounts were screened for any protozoan trophozoite / cyst and helminthic ova which were identified on the basis of their characteristic morphological features. Results A total of 755 stool samples were analyzed, out of which, 133 samples were found to be positive for parasitic infections, with a prevalence rate of 17.6%. Among positive samples Entamoeba histolytica was found to be the most common parasite in 70 (9.3%) cases, followed by Blastocystis hominis in 25 (3.3%), Giardia lamblia in 23 (3%), Ascaris lumbricoides in 10 (1.3%), Ancyclostoma duodenale in 3 (0.4%) and Hymenolepis nana in only 2 (0.3%) cases (Table 1, Figure 1). Parasitic infections were more common in male patients (10%) compared to their female (7.55%) counterparts. Statistically significant difference was found in male female distribution of E. histolytica was seen (p<0.05) (Table 2). In different age groups years group (6%) was most commonly affected followed by 5-20 years, years, 0-5 years and lastly >60 yrs, with a prevalence rate of 3.8, 3.2, 3 and 1.6% respectively (Table 3). Indian Journal of Basic and Applied Medical Research Is now with IC value

3 Table 1: Prevalence of intestinal parasites in positive stool samples Name of parasite N (%) E.histolytica 70 (9.3) B. hominis 25 (3.3) G.lambia 23 (3.0) A. lumbricoides 10 (1.3) A.duodenale 3 (0.4) H. nana 2 (0.3) TOTAL 133 (17.6) Figure 1: Prevalence of different intestinal parasites

4 Table 2: Gender based distribution of intestinal parasites Name of parasites Total Number Male Female M: F p value (%) n (%) n (%) Ratio Entamoeba histolytica 70 (9.3) 44 (5.8) 26 (3.5) 1.7: * Blastocystis hominis 25 (3.3) 10 (1.3) 15 (2.0) 1: Giardia lambia 23 (3.0) 10(1.3) 15 (1.7) 1: Ascaris lumbricoides 10 (1.3) 7(0.9) 3(0.4) 2.5: Ancylostoma duodenale 3 (0.4) 3 (0.4) 00 N.A Hymenolepis nana 2 (0.3) 2 (0.3) 00 N.A TOTAL 133 (17.6) 76 (10.0) 57 (7.6) 1.3: Table 3: Distribution of various intestinal parasites in different age groups PARASITE N (%) 0-5 yrs 5-20yrs yrs 41-60yrs >60 yrs E.histolytica 70 (9.3) B.hominis 25 (3.3) G.lambia 23 (3.0) A lumbricoides 10 (1.3) A. duodenale 3 (0.4) H.nana 2 (0.3) Total N (%) 133 (17.6) 23 (3.0) 29 (3.8) 45 (6.0) 24 (3.2) 12 (1.6)

5 Table 4: Prevalence of common intestinal parasites reported between from India Study details Sample size Prevalence (%) of common intestinal parasites Authors, year and place of study N + ve % E. histolytica G. lamblia B. hominis A. lumbricoides H. nana A. duodenale Ragunathan et al., 2010 (Puducherry) Aher and Kulkarni, 2011 (Ahmednagar) Rashid et al, 2011 (Bareilly) Bisht et al, 2012 (Ghaziabad) Singh et al, 2012 (Indore) Kotian et al, 2013 (Srinagar, UK) Present study, 2014 (Lucknow) Discussion parasites was 11.5%, (5.4% in Alambagh and 20.8% Out of total 755 stool samples examined during the in Mati)(19). The wide variations in the prevalence of study, 133 (17.6%) were positive for at least one intestinal parasites are multifactorial and related to parasite, which is comparable to previous studies by quality of potable water, personal hygiene and Singh et al. (13.9%) (12), Kotian et al (11.62%) (13). sanitation and other environmental conditions. However, many studies have reported higher In our study male patients were more commonly prevalence rate in the range of % and few affected (10%) compared to their female counterparts studies have reported low prevalence of around (7.6%), male female ratio was 1.3:1 (Table 2). This is 6.63% (6, 11, 15) (Table 4). Various studies from comparable to few previous studies by Singh et al India have reported a prevalence rate in the range of and Rao et al (20, 21). This can be explained by 12.5% to 66% (16, 17, 18). Nevertheless, more outdoor activities by them compared to prevalence rate is comparable to a previous study females, however reverse ratio has been reported by done by Nitin S et al, in Alambagh and Mati area of few workers (13, 22). It can be inferred that results 564 Lucknow, in which overall prevalence of intestinal depend on daily activities and personal hygiene rather

6 than type of gender (12). In age-wise distribution, yrs age group was the commonest (6%) followed by 5-20 years (Table 2). This can be result of higher outdoor activities by the persons belonging to middle age, young adult and adolescent age groups. Protozoan intestinal parasites namely Entamoeba histolytica, Giardia lamblia and Blastocystis hominis were cause of infection in majority (15.6%) of patients compared to helminths (2.0%). This is comparable to previous studies done by Singh et al and Bisht et al., but few other workers have reported helminths as major intestinal pathogens (6, 11-15) (Table 4). Decrease in prevalence of soil transmitted helminthes can be explained by efforts taken up by WHO in deworming the population at risk, particularly school age children (SAC) to meet the Millennium Development Goals (MDG). Currently, only about 10 per cent of SAC and 20 per cent of preschool children who are at risk of acquiring intestinal helminth infections are dewormed against the target set by WHO to regularly treat at least 75 per cent of SAC at risk of morbidity (23). One of the important finding of this study is prevalence of B. hominis (3.3%) cases, which has not been reported from North India at such a good prevalence rate. Kumar et al. have reported only two cases of B. hominis from North India previously (24) The organism was initially considered to be a commensal, but later observations and studies strongly suggest it to be a pathogen. Although this is supported by strong clinical and scientific evidences, the virulence factors, pathogenicity and other risk factors involved in disease manifestation are still obscure (25). Patients infected with Blastocystis frequently present with gastrointestinal complaints and are treated with the intention to eradicate the parasite (26) and recent data also suggest that Blastocystis causes symptoms frequently. Therefore, therapy should be limited to patients with persistent symptoms subsequent to a complete work up for alternative etiologies (27). Conclusion Following important conclusions can be drawn from the study, first, mass deworming programme of SAC by WHO are showing results by decrease in prevalence of STH, second, B. hominis is emerging as a new protozoan enteric pathogen and needs better laboratory techniques for diagnosing and last but not the least, higher prevalence of protozoan parasites reaffirms the need of interventional measures, health education of school going children, maintenance of proper hand hygiene, provision of safe drinking water, proper waste disposal, identifying and treating infected as well as asymptomatic individuals. Nevertheless, a larger cross sectional population based study is needed to confirm findings of our study, especially prevalence and role of B. hominis in gastrointestinal pathogenesis. References 1. Steketee RW. Pregnancy, nutrition and parasitic diseases. J Nutr. 2003;133:1661S 1667S 2. Damen J. G., Luka J, Lugos, M. Prevalence of intestinal parasites among pupils in rural North Eastern, Nigeria. Niger Med J 2011;1: Mehraj V, Hatcher J, Akhtar S, Rafique G, Beg MA. Prevalence and factors associated with Intestinal parasitic infection among children in an urban slum of Karachi. PLoSOne 2008;3: World Health Organization. Control of Tropical Diseases. Geneva, Switzerland: WHO;

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